Prevention of Wrong Site Surgery, Retained Surgical Items, and Surgical Fires: A Systematic Review

[1]  Johan F. Lange,et al.  Participatory design: implementation of time out and debriefing in the operating theatre , 2011 .

[2]  Janice S. Lee,et al.  Prevention of wrong-site tooth extraction: clinical guidelines. , 2007, Journal of oral and maxillofacial surgery : official journal of the American Association of Oral and Maxillofacial Surgeons.

[3]  M. Makary,et al.  Surgical never events in the United States. , 2013, Surgery.

[4]  Carl E Fabian,et al.  Electronic tagging of surgical sponges to prevent their accidental retention. , 2005, Surgery.

[5]  Mandie Street,et al.  Creating and evaluating a data-driven curriculum for central venous catheter placement. , 2010, Journal of Graduate Medical Education.

[6]  Steven L. Lee The extended surgical time-out: does it improve quality and prevent wrong-site surgery? , 2010, The Permanente journal.

[7]  Abha Agrawal,et al.  Counting matters: lessons from the root cause analysis of a retained surgical item. , 2012, Joint Commission journal on quality and patient safety.

[8]  M. Archdeacon,et al.  Pulsatile lavage irrigator tip, a rare radiolucent retained foreign body in the pelvis: a case report , 2011, Patient safety in surgery.

[9]  S. Kelly,et al.  Wrong intraocular lens implant; learning from reported patient safety incidents , 2011, Eye.

[10]  Lee P. Smith,et al.  Operating room fires in otolaryngology: risk factors and prevention. , 2011, American journal of otolaryngology.

[11]  B. Coldiron,et al.  Outcome of 6 years of protocol use for preventing wrong site office surgery. , 2011, Journal of the American Academy of Dermatology.

[12]  A. Macario,et al.  Improving safety in the operating room: a systematic literature review of retained surgical sponges , 2009, Current opinion in anaesthesiology.

[13]  S. Panesar,et al.  National Patient Safety Agency leads national implementation of measures to reduce the incidence of retained surgical materials. , 2010, The surgeon : journal of the Royal Colleges of Surgeons of Edinburgh and Ireland.

[14]  Stuart R. Lipsitz,et al.  The Frequency and Significance of Discrepancies in the Surgical Count , 2008, Annals of surgery.

[15]  R. Hemphill,et al.  Sharing Lessons Learned to Prevent Incorrect Surgery , 2012, The American surgeon.

[16]  Michele M Pelter,et al.  An evaluation of a numbered surgical sponge product. , 2007, AORN journal.

[17]  J. Simon Preventing surgical confusions in ophthalmology (an American Ophthalmological Society thesis). , 2007, Transactions of the American Ophthalmological Society.

[18]  A. Kwan The use of Storz bronchoscope in prevention of airway fire. , 2004, Anaesthesia and intensive care.

[19]  D. Denk,et al.  Superimposed high-frequency jet ventilation (SHFJV) for endoscopic laryngotracheal surgery in more than 1500 patients. , 2006, British journal of anaesthesia.

[20]  D. Chang,et al.  The Error of Omission: A Simple Checklist Approach for Improving Operating Room Safety , 2009, Plastic and reconstructive surgery.

[21]  Donald L. Miller,et al.  Quality improvement guidelines for preventing wrong site, wrong procedure, and wrong person errors: application of the joint commission "Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery" to the practice of interventional radiology. , 2008, Journal of vascular and interventional radiology : JVIR.

[22]  James L. Zehnder,et al.  High-throughput VDJ sequencing for quantification of minimal residual disease in chronic lymphocytic leukemia and immune reconstitution assessment , 2011, Proceedings of the National Academy of Sciences.

[23]  M. Leonard,et al.  The human factor: the critical importance of effective teamwork and communication in providing safe care , 2004, Quality and Safety in Health Care.

[24]  Elizabeth K. Norton,et al.  Patients count on it: an initiative to reduce incorrect counts and prevent retained surgical items. , 2012, AORN journal.

[25]  G. Liguori,et al.  Two Cases of a Wrong-Site Peripheral Nerve Block and a Process to Prevent This Complication , 2004, Regional Anesthesia & Pain Medicine.

[26]  Tina Rutar,et al.  Errors in strabismus surgery. , 2013, JAMA ophthalmology.

[27]  Claude Deschamps,et al.  Using a data-matrix-coded sponge counting system across a surgical practice: impact after 18 months. , 2011, Joint Commission journal on quality and patient safety.

[28]  Liza Chan,et al.  Retained surgical items: a problem yet to be solved. , 2013, Journal of the American College of Surgeons.

[29]  A. Dellon,et al.  Historical development of bipolar coagulation , 2010, Microsurgery.

[30]  Diane B Kimsey,et al.  Patient safety: break the silence. , 2012, AORN journal.

[31]  Kimberly A. Kressin Burn Injury in the Operating Room: A Closed Claims Analysis , 2004 .

[32]  A. Nowitzke,et al.  Improving accuracy and reducing errors in spinal surgery--a new technique for thoracolumbar-level localization using computer-assisted image guidance. , 2008, The spine journal : official journal of the North American Spine Society.

[33]  B. Gillespie,et al.  Teamwork in the OR: Enhancing communication through team-building interventions , 2008 .

[34]  L. Donaldson,et al.  Alcohol skin preparation causes surgical fires. , 2012, Annals of the Royal College of Surgeons of England.

[35]  A. McIndoe,et al.  Fires and explosions , 2004 .

[36]  Cathy Sechrist,et al.  Retained foreign bodies after surgery. , 2006, The Journal of surgical research.

[37]  Stuart R. Lipsitz,et al.  Bar-coding Surgical Sponges To Improve Safety: A Randomized Controlled Trial , 2008, Annals of surgery.

[38]  Jodi A. Berendzen,et al.  Fire in labor and delivery: simulation case scenario. , 2011, Simulation in healthcare : journal of the Society for Simulation in Healthcare.

[39]  E. Duthie Application of Human Error Theory in Case Analysis of Wrong Procedures , 2010, Journal of patient safety.

[40]  T. Hunter,et al.  Identification of retained surgical foreign objects: policy at a university medical center. , 2010, Journal of the American College of Radiology : JACR.

[41]  Jane Flowers,et al.  Code red in the OR----implementing an OR fire drill. , 2004, AORN journal.

[42]  K. Bani-Hani,et al.  Retained surgical sponges (gossypiboma). , 2005, Asian journal of surgery.

[43]  Alan S Crandall,et al.  Intraocular lens exchange due to incorrect lens power. , 2007, Ophthalmology.

[44]  P. Patterson RI standardizes safe-site protocol. , 2009, OR manager.

[45]  Gary Hooper,et al.  The Time Out Procedure: have we changed our practice? , 2012, The New Zealand medical journal.

[46]  Katarzyna Sygit,et al.  Migration of a foreign body into the colon and its autonomous excretion , 2011, Medical science monitor : international medical journal of experimental and clinical research.

[47]  Janet Chadwick,et al.  Effectiveness of a radiofrequency detection system as an adjunct to manual counting protocols for tracking surgical sponges: a prospective trial of 2,285 patients. , 2012, Journal of the American College of Surgeons.

[48]  Rebecca A Russell,et al.  Implementing a regional anesthesia block nurse team in the perianesthesia care unit increases patient safety and perioperative efficiency. , 2013, Journal of perianesthesia nursing : official journal of the American Society of PeriAnesthesia Nurses.

[49]  Yasuharu Okuda,et al.  Preventing Wrong-Site Invasive Procedures Outside the Operating Room: A Thoracentesis Simulation Case Scenario , 2013, Simulation in healthcare : journal of the Society for Simulation in Healthcare.

[50]  Sheri L. Zastrow Adapting the JCAHO Protocol for perioperative quality care. , 2006, Journal of continuing education in nursing.

[51]  P. Mahar,et al.  Interventions for reducing wrong-site surgery and invasive procedures. , 2012, The Cochrane database of systematic reviews.

[52]  K Moorthy,et al.  Practical challenges of introducing WHO surgical checklist: UK pilot experience , 2010, BMJ : British Medical Journal.

[53]  C. DiGiovanni,et al.  Patient Compliance in Avoiding Wrong-Site Surgery , 2003, The Journal of bone and joint surgery. American volume.

[54]  P. Patterson Pinpointing risks of wrong surgery. , 2011, OR manager.

[55]  V. Steelman,et al.  Where There's Smoke, There's.... , 2009, AORN journal.

[56]  M. Paradisi,et al.  Avoiding surgical errors by referencing anatomical landmarks , 2012, The British journal of dermatology.

[57]  D. Fairchild,et al.  Monitoring universal protocol compliance through real-time clandestine observation by medical students results in performance improvement. , 2012, Journal of surgical education.

[58]  W. Berry,et al.  A Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global Population , 2009, The New England journal of medicine.

[59]  R. Caplan,et al.  Practice Advisory for the Prevention and Management of Operating Room Fires: An Updated Report by the American Society of Anesthesiologists Task Force on Operating Room Fires , 2013, Anesthesiology.

[60]  J. Ryu,et al.  Sterility of surgical site marking. , 2005, The Journal of bone and joint surgery. American volume.

[61]  Marlena H. Shin,et al.  Detecting patient safety indicators: How valid is "foreign body left during procedure" in the Veterans Health Administration? , 2011, Journal of the American College of Surgeons.

[62]  J. Beesley,et al.  Reducing the Risk of Surgical Fires: Are you Assessing the Risk? , 2006, Journal of perioperative practice.

[63]  M. Zestos,et al.  Electrocautery-induced fire during adenotonsillectomy: report of two cases. , 2006, Journal of clinical anesthesia.

[64]  S. Seiden,et al.  Wrong-Site Surgeries Are Preventable—Reply , 2007 .

[65]  Nirmal C Tejwani,et al.  Patient Participation in Surgical Site Marking: Can This Be an Additional Tool to Help Avoid Wrong-Site Surgery? , 2010, Journal of patient safety.

[66]  S. Moffatt-Bruce,et al.  Preventing Wrong Site, Procedure, and Patient Events Using a Common Cause Analysis , 2012, American journal of medical quality : the official journal of the American College of Medical Quality.

[67]  E. M. Edel Surgical count practice variability and the potential for retained surgical items. , 2012, AORN journal.

[68]  S. Saha,et al.  Gossypiboma and Surgeon- Current Medicolegal Aspect – A Review , 2012, Indian Journal of Surgery.

[69]  Kathryn W White,et al.  Fire in the operating room during tracheotomy: a case report. , 2005, AANA journal.

[70]  D. Blackhurst,et al.  Analysis of Centers for Medicaid and Medicare Services ‘Never Events’ in Elderly Patients Undergoing Bowel Operations , 2010, The American surgeon.

[71]  P. Mummaneni,et al.  Avoidance of wrong-level thoracic spine surgery: intraoperative localization with preoperative percutaneous fiducial screw placement. , 2012, Journal of neurosurgery. Spine.

[72]  Verna C. Gibbs,et al.  Retained Surgical Items and Minimally Invasive Surgery , 2011, World Journal of Surgery.

[73]  Christopher I Shaffrey,et al.  A survey-based study of wrong-level lumbar spine surgery: the scope of the problem and current practices in place to help avoid these errors. , 2013, World neurosurgery.

[74]  P. Patterson Hardwiring the right-site process. , 2011, OR manager.

[75]  S. Palmer,et al.  Left behind: unintentionally retained surgically placed foreign bodies and how to reduce their incidence--self-assessment module. , 2009, AJR. American journal of roentgenology.

[76]  D. Chang,et al.  Flash fires during facial surgery: recommendations for the safe delivery of oxygen. , 2007, Plastic and reconstructive surgery.

[77]  P. Dejohn Joint Commission tools to prevent wrong surgery. , 2012, OR manager.

[78]  M. Raval,et al.  Beware of the flaming hairball--a brief review and warning. , 2005, Journal of pediatric surgery.

[79]  L. Rosenfield Flash fires during facial surgery: reply. , 2008, Plastic and reconstructive surgery.

[80]  Mary Cooper,et al.  Managing the Prevention of Retained Surgical Instruments: What Is the Value of Counting? , 2008, Annals of surgery.

[81]  Matthew D Ammerman,et al.  A prospective evaluation of the role for intraoperative x-ray in lumbar discectomy. Predictors of incorrect level exposure. , 2006, Surgical neurology.

[82]  J. Duncan,et al.  Retained Guidewires After Intraoperative Placement of Central Venous Catheters , 2013, Anesthesia and analgesia.

[83]  S. Becker,et al.  A review of malpractice cases after tonsillectomy and adenoidectomy. , 2010, International journal of pediatric otorhinolaryngology.

[84]  P Garnerin,et al.  Verifying patient identity and site of surgery: improving compliance with protocol by audit and feedback , 2008, Quality & Safety in Health Care.

[85]  Julia F. Lippert,et al.  An Assessment of the Occupational Hazards Related to Medical Lasers , 2011, Journal of occupational and environmental medicine.

[86]  J. Aucar,et al.  Use of an anatomic marking form as an alternative to the Universal Protocol for Preventing Wrong Site, Wrong Procedure and Wrong Person Surgery. , 2010, American journal of surgery.

[87]  K. Chung,et al.  Complications in Surgery: Root Cause Analysis and Preventive Measures , 2012, Plastic and reconstructive surgery.

[88]  James P Bagian,et al.  Incorrect surgical procedures within and outside of the operating room: a follow-up report. , 2011, Archives of surgery.

[89]  Philip F Stahel,et al.  Wrong-site and wrong-patient procedures in the universal protocol era: analysis of a prospective database of physician self-reported occurrences. , 2010, Archives of surgery.

[90]  Mary R. Kwaan,et al.  Incidence, patterns, and prevention of wrong-site surgery. , 2006, Archives of surgery.

[91]  J. Dettori,et al.  Avoiding Wrong Site Surgery: A Systematic Review , 2010, Spine.

[92]  M. Levy,et al.  Gel-based surgical preparation resulting in an operating room fire during a neurosurgical procedure: case report. , 2005, Journal of neurosurgery.

[93]  S. Varma,et al.  The use of a hand‐held mirror to reduce litigation and improve communication in dermatological surgery , 2012, The British journal of dermatology.

[94]  C. Corona,et al.  How to avoid wrong-level and wrong-side errors in lumbar microdiscectomy. , 2010, Journal of neurosurgery. Spine.

[95]  Yasuko Tomizawa,et al.  Crisis in the operating room: fires, explosions and electrical accidents , 2010, Journal of Artificial Organs.

[96]  B.H. Jeong,et al.  An RFID Application Model For Surgery Patient Identification , 2008, 2008 IEEE Symposium on Advanced Management of Information for Globalized Enterprises (AMIGE).

[97]  Donna Castelluccio Implementing AORN Recommended Practices for Laser Safety. , 2012, AORN journal.

[98]  C. Fager Malpractice issues in neurological surgery. , 2006, Surgical neurology.

[99]  L. K. Hardee Quality improvement: universal protocol use in office-based gastrointestinal procedure units. , 2012, Gastroenterology nursing : the official journal of the Society of Gastroenterology Nurses and Associates.

[100]  Rebecca L Wu,et al.  Characteristics and costs of surgical scheduling errors. , 2012, American journal of surgery.

[101]  S. DeMaria,et al.  Management of intraoperative airway fire. , 2011, Simulation in healthcare : journal of the Society for Simulation in Healthcare.

[102]  Chuan-Jun Su,et al.  Improving Patient Safety and Control in Operating Room by Leveraging RFID Technology , 2009 .

[103]  Claude Deschamps,et al.  Role of the surgeon in quality and safety in the operating room environment , 2012, General Thoracic and Cardiovascular Surgery.

[104]  K. Mattucci,et al.  Use of the Laryngeal Mask Airway in Preventing Airway Fires during Adenoidectomies in Children: A Study of 25 Patients , 2007, Ear, nose, & throat journal.

[105]  Muhammad Jaffar,et al.  Preventing operating room fire: an alternate approach. , 2006, Anesthesia and analgesia.

[106]  Cidalia J. Vital,et al.  Joint Commission and Universal Protocol- Adapting Changes to The Marking Process , 2011 .

[107]  P. Rhee,et al.  Retained Foreign Bodies after Emergent Trauma Surgery: Incidence after 2526 Cavitary Explorations , 2007, The American surgeon.

[108]  Lorri A. Lee,et al.  Closed claims' analysis. , 2011, Best practice & research. Clinical anaesthesiology.

[109]  G. Johnston,et al.  Surgical site signing and "time out": issues of compliance or complacence. , 2009, The Journal of bone and joint surgery. American volume.

[110]  J. Defontes,et al.  Preoperative Safety Briefing Project. , 2004, The Permanente journal.

[111]  Claude Deschamps,et al.  Surgical case listing accuracy: failure analysis at a high-volume academic medical center. , 2010, Archives of surgery.

[112]  F Dean Griffen,et al.  The American College of Surgeons' closed claims study: new insights for improving care. , 2007, Journal of the American College of Surgeons.

[113]  L. Butcher Wrong-site surgery. , 2011, Hospitals & health networks.

[114]  B. Segal,et al.  Critical action procedures testing: a novel method for test‐enhanced learning , 2009, Medical education.

[115]  D. France,et al.  An observational analysis of surgical team compliance with perioperative safety practices after crew resource management training. , 2008, American journal of surgery.

[116]  R. Perlis,et al.  Incidence of and Risk Factors for Medical Malpractice Lawsuits among Mohs Surgeons , 2006, Dermatologic surgery : official publication for American Society for Dermatologic Surgery [et al.].

[117]  J. Simon,et al.  Surgical confusions in ophthalmology. , 2007, Archives of ophthalmology.

[118]  Mark Bernstein,et al.  Wrong-site craniotomy: analysis of 35 cases and systems for prevention. , 2010, Journal of neurosurgery.

[119]  Subhas C. Gupta,et al.  The Battle of Words and the Reality of Never Events in Breast Reconstruction: Incidence, Risk Factors Predictive of Occurrence, and Economic Cost Analysis , 2012, Plastic and reconstructive surgery.

[120]  John R Clarke,et al.  Wrong site surgery near misses and actual occurrences. , 2009, AORN journal.

[121]  S. Palmer,et al.  Left behind: unintentionally retained surgically placed foreign bodies and how to reduce their incidence--pictorial review. , 2009, AJR. American journal of roentgenology.

[122]  C. Divino,et al.  Integration of a formalized handoff system into the surgical curriculum: resident perspectives and early results. , 2011, Archives of surgery.

[123]  Michael Kranzfelder,et al.  Real-time monitoring for detection of retained surgical sponges and team motion in the surgical operation room using radio-frequency-identification (RFID) technology: a preclinical evaluation. , 2012, The Journal of surgical research.

[124]  B. Ackerman,et al.  Burn Center Management of Operating Room Fire Injuries , 2012, Journal of burn care & research : official publication of the American Burn Association.

[125]  C. Nicholson,et al.  Side errors in neurosurgery , 2006, Acta Neurochirurgica.

[126]  J. Klopfenstein,et al.  Incidence of neurosurgical wrong-site surgery before and after implementation of the universal protocol. , 2013, Neurosurgery.

[127]  Michael A Ricci,et al.  Crew resource management: using aviation techniques to improve operating room safety. , 2012, Aviation, space, and environmental medicine.

[128]  P. Patterson Preventing retained surgical items: what role does technology play? , 2009, OR manager.

[129]  Bethany Daily,et al.  Automatic Detection and Notification of “Wrong Patient—Wrong Location” Errors in the Operating Room , 2005, Surgical innovation.

[130]  R. Ersek Flash fires during facial surgery. , 2008, Plastic and reconstructive surgery.

[131]  J. Neily,et al.  Incorrect surgical procedures within and outside of the operating room. , 2009, Archives of surgery.

[132]  S. Rogers,et al.  Communication and culture: opportunities for safer surgery , 2009, Quality & Safety in Health Care.

[133]  K. Laudanski,et al.  Surgical Fire During Organ Procurement , 2008 .

[134]  T. Cobb Wrong site surgery—where are we and what is the next step? , 2012, Hand.

[135]  Debbie Sandlin,et al.  SurgiChip--new technology for prevention of wrong site, wrong procedure, wrong person surgery. , 2005, Journal of perianesthesia nursing : official journal of the American Society of PeriAnesthesia Nurses.

[136]  Duncan Clarke,et al.  Active-RFID System Accuracy and Its Implications for Clinical Applications , 2006, 19th IEEE Symposium on Computer-Based Medical Systems (CBMS'06).

[137]  G. Richter,et al.  Suction cautery and electrosurgical risks in otolaryngology. , 2008, International journal of pediatric otorhinolaryngology.

[138]  David W Roberson,et al.  Wrong-site sinus surgery in otolaryngology , 2010, Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery.

[139]  John Morley,et al.  The New York Model: Root Cause Analysis Driving Patient Safety Initiative to Ensure Correct Surgical and Invasive Procedures , 2008 .

[140]  N. Martin,et al.  University of California, Los Angeles, surgical time-out process: evolution, challenges, and future perspective. , 2012, Neurosurgical focus.

[141]  A. Schachat,et al.  Lessons learned: wrong intraocular lens. , 2012, Ophthalmology.

[142]  M. Stoneham Warning: Increased Risk of Surgical Fire , 2009 .

[143]  K. Mason,et al.  The Evolution of Universal Protocol in Interventional Radiology , 2006 .

[144]  Jason W Harrington Surgical time outs in a combat zone. , 2009, AORN journal.

[145]  James G Wright,et al.  Evaluation of preoperative and perioperative operating room briefings at the Hospital for Sick Children. , 2009, Canadian journal of surgery. Journal canadien de chirurgie.

[146]  P. Mills,et al.  Developing Unique Engineering Solutions to Improve Patient Safety , 2012 .

[147]  Elizabeth K. Norton Using an alternative site marking form to comply with the Universal Protocol. , 2011, AORN journal.

[148]  R. May,et al.  Incidence of Wrong-Site Surgery Among Foot and Ankle Surgeons , 2011, Foot & ankle specialist.

[149]  Mu-Chun Su,et al.  Application of radio-frequency identification in perioperative care. , 2011, AORN journal.

[150]  M. Lypson,et al.  Preventing surgical fires: who needs to be educated? , 2005, Joint Commission journal on quality and patient safety.

[151]  E. Deutsch,et al.  Variation in surgical time-out and site marking within pediatric otolaryngology. , 2011, Archives of otolaryngology--head & neck surgery.

[152]  Mohammad Alfawareh,et al.  The Prevalence of Wrong Level Surgery Among Spine Surgeons , 2008, Spine.

[153]  M. Aşırdizer,et al.  The importance of medico-legal evaluation in a case with intraabdominal gossypiboma. , 2010, Forensic science international.

[154]  J. Kelly,et al.  A survey of the use of time-out protocols in emergency medicine. , 2011, Joint Commission journal on quality and patient safety.

[155]  A. Sheikh,et al.  Can the surgical checklist reduce the risk of wrong site surgery in orthopaedics? - can the checklist help? Supporting evidence from analysis of a national patient incident reporting system , 2011, Journal of orthopaedic surgery and research.

[156]  T. Ikonen,et al.  A pilot study of the implementation of WHO Surgical Checklist in Finland: improvements in activities and communication , 2011, Acta anaesthesiologica Scandinavica.

[157]  P. Pronovost,et al.  Clinical review: Checklists - translating evidence into practice , 2009, Critical care.

[158]  Marlene R. Miller,et al.  Tracking progress in patient safety: an elusive target. , 2006, JAMA.

[159]  Edna Zohar,et al.  Perioperative Patient Safety: Correct Patient, Correct Surgery, Correct Side—A Multifaceted, Cross-Organizational, Interventional Study , 2007, Anesthesia and analgesia.

[160]  Claude Deschamps,et al.  Incidence and characteristics of potential and actual retained foreign object events in surgical patients. , 2008, Journal of the American College of Surgeons.

[161]  Cheryl A Weisbrod,et al.  A multidisciplinary team approach to retained foreign objects. , 2009, Joint Commission journal on quality and patient safety.

[162]  V. Denaro,et al.  Errors of level in spinal surgery: an evidence-based systematic review. , 2012, The Journal of bone and joint surgery. British volume.

[163]  V. Steelman,et al.  Assessment of radiofrequency device sensitivity for the detection of retained surgical sponges in patients with morbid obesity. , 2012, Archives of surgery.

[164]  Warren S. Sandberg,et al.  A computerized perioperative data integration and display system , 2007, International Journal of Computer Assisted Radiology and Surgery.

[165]  Wilhelm K. Schwab,et al.  Thermal damage of the humidified ventilator circuit in the operating room: an analysis of plausible causes. , 2010, Anesthesia and analgesia.

[166]  James B. Hill,et al.  Implementation of a protocol to reduce occurrence of retained sponges after vaginal delivery. , 2011, Military medicine.

[167]  James H Herndon,et al.  Medical errors in orthopaedics. Results of an AAOS member survey. , 2009, The Journal of bone and joint surgery. American volume.

[168]  Anurag Tripathi,et al.  Microfrabricated instrument tag for the radiographic detection of retained foreign bodies during surgery , 2012, Medical Imaging.

[169]  M. Sosis Anesthesiologists must inform their surgical colleagues when there is a risk of an operating room fire. , 2005, Anesthesia and analgesia.

[170]  B. Toth,et al.  Fire in the operating room: principles and prevention. , 2005, Plastic and reconstructive surgery.

[171]  J. Furuno,et al.  Reducing the incidence of retained surgical instrument fragments. , 2011, AORN journal.

[172]  Yosuke Kurihara,et al.  Safe patient transfer system with monitoring of location and vital signs. , 2008, Journal of medical and dental sciences.

[173]  J. Zins,et al.  Operating Room Fires: Optimizing Safety , 2007, Plastic and reconstructive surgery.

[174]  A. Charles,et al.  Article Commentary: Retained Intra-abdominal Surgical Instruments: Time to Use Nascent Technology? , 2007, The American surgeon.

[175]  L. Donaldson,et al.  Surgical fires, a clear and present danger. , 2010, The surgeon : journal of the Royal Colleges of Surgeons of Edinburgh and Ireland.

[176]  Ramon Lopez,et al.  Contributing factors to fires in clinical settings during medical laser applications , 2012 .

[177]  G. Hooper,et al.  TIME OUT – AVOIDING WRONG SITE SURGERY – AN AUDIT OF SIX MONTHS EXPERIENCE , 2006 .

[178]  S. Moffatt-Bruce,et al.  Intravascular retained surgical items: a multicenter study of risk factors. , 2012, The Journal of surgical research.

[179]  Liane Salmon Fire in the OR--prevention and preparedness. , 2004, AORN journal.

[180]  Robert R Cima,et al.  Prevention of retained surgical sponges: a decision-analytic model predicting relative cost-effectiveness. , 2009, Surgery.

[181]  J. Harrast,et al.  The occurrence of wrong-site surgery self-reported by candidates for certification by the American Board of Orthopaedic Surgery. , 2012, The Journal of bone and joint surgery. American volume.

[182]  P. Healy Retained vaginal swabs: review of an adverse event in obstetrics through closed claims analysis , 2012 .

[183]  S. Duggineni Wrong side surgery , 2011, BDJ.

[184]  J. Davies,et al.  Preventing fires due to supplemental oxygen , 2011, Anaesthesia.

[185]  D. Dunn Surgical site verification: A through Z. , 2006, Journal of perianesthesia nursing : official journal of the American Society of PeriAnesthesia Nurses.

[186]  Peter J Pronovost,et al.  Operating room briefings and wrong-site surgery. , 2007, Journal of the American College of Surgeons.

[187]  M. Gunn,et al.  Gossypiboma: tales of lost sponges and lessons learned. , 2010, Archives of surgery.

[188]  D. Chang,et al.  Risk factors and outcomes for foreign body left during a procedure: analysis of 413 incidents after 1 946 831 operations in children. , 2010, Archives of surgery.

[189]  V. Asopa,et al.  Three ways to avoid incorrect-level lumbar spine surgery. , 2012, Annals of the Royal College of Surgeons of England.

[190]  S. Lampotang,et al.  Reducing the incidence of surgical fires: supplying nasal cannulae with sub-100% O2 gas mixtures from anesthesia machines. , 2005, Anesthesia and analgesia.

[191]  J. Clarke,et al.  Wrong-site surgery: can we prevent it? , 2008, Advances in surgery.

[192]  D. Feller-Kopman,et al.  Microdebrider bronchoscopy: a new tool for the interventional bronchoscopist. , 2005, The Annals of thoracic surgery.

[193]  A. G. Macdonald A brief historical review of non-anaesthetic causes of fires and explosions in the operating room. , 1994, British journal of anaesthesia.

[194]  R. Etienne-Cummings,et al.  Prevention and diagnosis of retained foreign bodies through the years: past, present, and future technologies. , 2012, Technology and health care : official journal of the European Society for Engineering and Medicine.